Provider Demographics
NPI:1366196461
Name:IMAC MEDICAL OF LOUISIANA A MEDICAL CORPORATION
Entity type:Organization
Organization Name:IMAC MEDICAL OF LOUISIANA A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BAILEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BOYETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-637-7333
Mailing Address - Street 1:1605 WESTGATE CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-8396
Mailing Address - Country:US
Mailing Address - Phone:844-266-4622
Mailing Address - Fax:615-637-7334
Practice Address - Street 1:1940 ONEAL LN
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-3201
Practice Address - Country:US
Practice Address - Phone:888-553-3689
Practice Address - Fax:225-751-6680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain